General: (516) 431-9191
Underwriting: (516) 431-6200 • Fax: (516) 431-0488
370 West Park Avenue, P.O. Box 9004, Long Beach, NY 11561-9004
www.lancerinsurance.com/commauto.html
Dealer & Transporter Plate Application
Policy Effective Date:
Quote Requested By Date:
1. Corporate or Individual Name (include DBA):
2. Company Type:
Individual
Corporation
Partnership
Other:
3. FEIN:
Federal Employer Identification Number is required for each corporate entity
4. Mailing Address:
Street
5.
6.
Business Tel:
(
)
Cell Phone #:
(
)
Contact Person:
Number of Years in Business:
City
Fax:
E-mail Address:
(
State
Zip
)
Title:
Type of Insured’s Operation:
COVERAGE INFORMATION
COVERAGES
LIMIT
COVERAGES
LIMIT
Auto Liability (Combined Single Limit)
$
Uninsured Motorist Protection (UM)
$
Personal Injury Protection (PIP)
$
Underinsured Motorist Protection (UIM)
$
# of Dealer Plates issued to you:
List each Dealer Plate number::
# of Transporter Plates issued to you:
List each Transporter Plate number::
# of Repairer Plates issued to you:
List each Repairer Plate number::
Note: Copy of current registration for each plate or authorization from Department of Motor Vehicles to act as a dealer is required
for coverage to be bound.
.
GENERAL INFORMATION
1. Do you rent, lease or loan autos to your customers?
Yes
No
2. Do you drive or otherwise transport vehicles for sale, repair, or pickup > 50 miles from your garage location?
Yes
No
What is your average trip?
miles
What is your maximum trip?
miles
3. Do you have any vehicles registered in the Corporate or Individual name listed above?
Yes
No
If Yes, complete the following schedule:
Year
Make
VIN
Insurance Carrier
Policy Number
Dealer & Transporter Plate Application (03/16)
Page 1 of 3
PRIOR INSURANCE HISTORY
Policy
Year
Carrier
Policy Number
1.
Is your present policy being cancelled?
Yes
2.
Please explain any prior gaps in insurance coverage:
No
Premium
No. of
Losses
Amount Paid
Total Incurred
$
$
$
$
$
$
If Yes, please explain:
DRIVER INFORMATION
Complete all sections below for all employees, non-employees, proprietors (both full and part time) and relatives who may use your dealer,
transporter and/or repairer plates. Use separate sheet to complete listing if needed. If driver is using plates for personal use, place a
checkmark in the box marked Personal Use.
Date of
Driver’s License Number and
Date
Personal
Name as it appears on
Street Address
Driver’s License
City, State & Zip
Birth
State
of Hire
Use
PLEASE ATTACH CURRENT MOTOR VEHICLE REPORT FOR EACH DRIVER LISTED ABOVE
ACCIDENTS & VIOLATIONS
List all accidents and moving violations for all drivers. Use separate sheet to complete listing if needed.
Operator
Dealer & Transporter Plate Application (03/16)
Description
Date
Page 2 of 3
PLEASE READ THE FOLLOWING CAREFULLY BEFORE YOU SIGN THIS APPLICATION.
I hereby apply for the insurance indicated above and represent that:
1) I have read this application.
2) The limits and coverages requested were selected by me.
3) All statements herein are true and accurate, to the best of my knowledge, and no material facts have been suppressed or
misstated. I understand that misrepresentation or omission of material facts will be cause for cancellation and may void
coverage.
4) By signing this application, I authorize the insurer to obtain copies of motor vehicle reports for underwriting the indicated
insurance, as well as the right to examine or inspect files, records, documents and equipment in order to determine the accuracy
of the information stated herein.
The completion of this application creates no express or implied obligation on the part of the insurer or its manager to offer a
quotation or provide insurance as requested in this application and survey. If the insurance is provided, the policy will only cover
the vehicles listed on the attached schedule for the coverages agreed. You must immediately notify the insurer in writing if there is
any change in your equipment or operations, and all accidents must be reported promptly regardless of severity or fault.
MANDATORY STATE FRAUD WARNINGS
NEW JERSEY: "ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS
SUBJECT TO CRIMINAL AND CIVIL PENALTIES."
PENNSYLVANIA: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION
OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL, UPON CONVICTION, BE SUBJECT TO
IMPRISONMENT FOR UP TO SEVEN YEARS AND PAYMENT OF A FINE OF UP TO $15,000.”
ALL OTHER STATES: "ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD."
Name of Insured (Print)
Name of Broker (Print)
Signature of Insured
Date
Signature of Broker Licensee
Date
(
)
Broker's Phone Number
Address of Broker
Broker’s Email Address
Are you the incumbent producer?
Yes
No
If No, name of incumbent:
Co-Broker's Name, Address and Phone Number
Dealer & Transporter Plate Application (03/16)
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